Bulletin of the World Health Organization
Volume 93, Number 2, February 2015, 65-132
http://www.who.int/bulletin/volumes/93/2/en/

SYSTEMATIC REVIEWS
The effectiveness of interventions to reduce the household economic burden of illness and injury: a systematic review
Beverley M Essue, Merel Kimman, Nina Svenstrup, Katharina Lindevig Kjoege, Tracey Lea Laba, Maree L Hackett & Stephen Jan
doi: 10.2471/BLT.14.139287
Abstract [HTML]
Objective
To determine the nature, scope and effectiveness of interventions to reduce the household economic burden of illness or injury.
Methods
We systematically reviewed reports published on or before 31 January 2014 that we found in the CENTRAL, CINAHL, Econlit, Embase, MEDLINE, PreMEDLINE and PsycINFO databases. We extracted data from prospective controlled trials and assessed the risk of bias. We narratively synthesized evidence.
Findings
Nine of the 4330 studies checked met our inclusion criteria – seven had evaluated changes to existing health-insurance programmes and two had evaluated different modes of delivering information. The only interventions found to reduce out-of-pocket expenditure significantly were those that eliminated or substantially reduced co-payments for a given patient population. However, the reductions only represented marginal changes in the total expenditures of patients. We found no studies that had been effective in addressing broader household economic impacts – such as catastrophic health expenditure – in the disease populations investigated.
Conclusion
In general, interventions designed to reduce the complex household economic burden of illness and injury appear to have had little impact on household economies. We only found a few relevant studies using rigorous study designs that were conducted in defined patient populations. The studies were limited in the range of interventions tested and they evaluated only a narrow range of household economic outcomes. There is a need for method development to advance the measurement of the household economic consequences of illness and injury and facilitate the development of innovative interventions to supplement the strategies based on health insurance.

Policy & Practice
Thresholds for the cost–effectiveness of interventions: alternative approaches
Elliot Marseille, Bruce Larson, Dhruv S Kazi, James G Kahn & Sydney Rosen
Many countries use the cost–effectiveness thresholds recommended by the World Health Organization’s Choosing Interventions that are Cost–Effective project (WHO-CHOICE) when evaluating health interventions. This project sets the threshold for cost–effectiveness as the cost of the intervention per disability-adjusted life-year (DALY) averted less than three times the country’s annual gross domestic product (GDP) per capita. Highly cost–effective interventions are defined as meeting a threshold per DALY averted of once the annual GDP per capita. We argue that reliance on these thresholds reduces the value of cost–effectiveness analyses and makes such analyses too blunt to be useful for most decision-making in the field of public health. Use of these thresholds has little theoretical justification, skirts the difficult but necessary ranking of the relative values of locally-applicable interventions and omits any consideration of what is truly affordable. The WHO-CHOICE thresholds set such a low bar for cost–effectiveness that very few interventions with evidence of efficacy can be ruled out. The thresholds have little value in assessing the trade-offs that decision-makers must confront. We present alternative approaches for applying cost–effectiveness criteria to choices in the allocation of health-care resources.

Perspectives
Rabies control in India: a need to close the gap between research and policy
Syed Shahid Abbas a & Manish Kakkar b
a. Institute of Development Studies, University of Sussex, Brighton, England.
b. Public Health Foundation of India, ISID Campus, 4 Vasant Kunj Institutional Area, New Delhi, 110070, India.
doi: http://dx.doi.org/10.2471/BLT.14.140723